1Calvary Health Care Bruce, Giralang , Australia
Sepsis and septic shock continues to be a major healthcare problem worldwide.
Australia’s Society of Critical Care Medicine’s Surviving Sepsis campaign highlighted that the early identification and appropriate management of sepsis improves patient outcomes. This recognition has bought about an increased focus on the definition of sepsis, with the third international consensus definition for sepsis and septic shock (Sepsis 3) being released in 2016. The definition of sepsis evolves in light of considerable advances in the understanding of sepsis’ pathobiology, management and epidemiology. The recommendations from Sepsis 3 were that sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. The quick Sequential (sepsis-related) Organ Failure Assessment (qSOFA) scoring system was developed from the work of the international consensus group on sepsis, as a bedside screening tool for clinicians to identify patients who may have a prolonged Intensive Care Unit stay or mortally due to sepsis. This tool identifies at risk patients who need timely targeted care to reduce associated morbidity and mortality.
Within our ED we modified existing sepsis pathways to incorporate the qSOFA tool to improve the recognition of patients with sepsis, enabling rapid intervention. As with all change, the pathway has had a mixed reaction from clinicians on the floor. During the implementation of the pathway, the primary concern was that the pathway was not capturing the right patients. Despite this concern, there has been an improvement in how we treat sepsis patients in the department.
qSOFA was one of the many contributing factors, alongside an increased department wide focus on sepsis and a clear treatment progression as laid out in the pathway. Due to the many factors involved, I would argue such improvements cannot be attributed to qSOFA alone. Other aspects of the pathway such as the empowerment of nursing staff to be able to recognise and initiate the sepsis pathway may have had a greater impact than qSOFA alone. This is not to suggest that qSOFA is not a valuable tool, yet qSOFA is a set of cues or prompts to suggest sepsis, the true detection of sepsis remains at the bedside, by a clinician.
Dale Reading is a registered nurse at the emergency department working at Calvary Public Hospital Bruce. Dale graduated from the University of Canberra with a Bachelor of Nursing and continued postgraduate studies in emergency nursing at the University of Tasmania. Dale has been involved in a number of quality improvement projects to improve clinical practice and is currently focused on nurse’s assessment of patient in the ED.
1Northpark Private Emergency Department, Bundoora, Australia
Evaluate the experience of commissioning a new Emergency Department, and strategies for building a new emergency team from the nurse manager perspective.
Review the requirements needed for commissioning of a new emergency department from the nurse unit managers perspective.
Retrospectively evaluate the core values and needs for building a successful team.
Understand and evaluate the strategies and phases of the recruitment process when building a new emergency nursing team.
Review of recommendations from governing bodies such as College of Emergency Nursing and Australian College of Emergency Medicine.
In November 2016 the Emergency Department was successfully opened in one of Australia’s biggest growth corridors to help meet the needs of the local community. There was successful recruitment of a highly skilled emergency nursing team that also met the needs of the community and organisation. A strong foundation was set for the new emergency nursing team to be successful and inspired with a focus towards ongoing professional development and the provision of excellent quality emergency care.
During the planning phases for the commissioning of a new Emergency Department it is important to understand the needs of the community when building a highly skilled, motivated and dedicated emergency nursing team. Understanding the requirements and aspects of building a successful team is core during the recruitment phase to ensure you have the ‘right people for the right job’.
Vanessa Gorman commenced her emergency nursing career in 1996 at Austin Hospital, Melbourne. Across her 20 year career in emergency nursing she has held positions such as Associate Unit Manager, Nurse Unit Manager, Project Manager, Senior Policy Advisor – Department of Health, Bed Access Coordinator, Nursing Educator and State Trauma Manager. Vanessa holds an enduring passion for trauma nursing and is an accredited international trauma coder and actively works with the State Trauma Registry in Victoria. Vanessa holds post-graduate qualifications in Emergency Nursing and is currently completing a Masters in Health Services Management through Monash University. Vanessa is an appointed member to the International Advisory Council for the Emergency Nursing Association (USA), which aims to make improvements within emergency nursing globally. Vanessa is dedicated to improving nursing work conditions with a particular interest in fatigue management. In 2015 she was co-lead in a Worksafe Victoria project with a focus on fatigue management for Emergency Nurses.
Mrs Vanessa Gorman1, Ms Emily Knights1,2
1Northpark Private Emergency Department, Bundoora, Australia, 2Melbourne University, Melbourne, Australia
OBJECTIVE: Discharge processes and instructions from emergency departments can expose patients to complications. Does telephone follow up 24-72hours post discharge lead to improved patient outcomes and alleviate any concerns with the discharge plan instructions?
METHODS: A 6 month retrospective analysis of nurse telephone call-back post discharge from an emergency department.
ED patients were followed up by a nurse within 72 hours of discharge. Nurses who made the telephone calls adhered to a script.
Patients with Glasgow Coma Scale>15, interviews were obtained from either the patient, primary care giver or from legal guardians of children (0-18yo). There were up to 3 attempts to contact each patient. Clinical advice was given using a medical escalation algorithm.
Deteriorating patients – meeting pre-specified criteria – were asked to return to the ED for assessment.
RESULTS: We followed up 400 patients who attended the ED and were discharged home. Significant deterioration was observed in around 1 in 20 patients, these patients were asked to return to the emergency department for re-evaluation resulting in improved patient outcomes. Discharge plan instructions were re-explained in over a quarter of all patients discharge which included information and advice about medication administration and when to see specialist, general practitioner or allied health professional. Patient feedback was positive.
CONCLUSIONS: Nurse follow-up phone calls may be an effective way to determine patients clinical state post discharge from the emergency department. It may determine any issues, clinical deterioration or concerns about discharge plan instructions.
Vanessa Gorman commenced her emergency nursing career in 1996 at Austin Hospital, Melbourne. Across her 20 year career in emergency nursing she has held positions such as Associate Unit Manager, Nurse Unit Manager, Project Manager, Senior Policy Advisor – Department of Health, Bed Access Coordinator, Nursing Educator and State Trauma Manager. Vanessa holds an enduring passion for trauma nursing and is an accredited international trauma coder and actively works with the State Trauma Registry in Victoria.
Vanessa holds post-graduate qualifications in Emergency Nursing and is currently completing a Masters in Health Services Management through Monash University. Vanessa is an appointed member to the International Advisory Council for the Emergency Nursing Association (USA), which aims to make improvements within emergency nursing globally. Vanessa is dedicated to improving nursing work conditions with a particular interest in fatigue management. In 2015 she was co-lead in a Worksafe Victoria project with a focus on fatigue management for Emergency Nurses.
Prof. Margaret Fry1,2, Professor Lynn Chenoweth3, Professor Glenn Arendts4
1University Of Technology Sydney, Broadway, Australia; 2Northern Sydney Local Health District, St Leonards, Australia; 3University of New South Wales, Randwick, Australia; 4University of Western Australia, Perth, Australia
Introduction: Unless pain is recognised and attended to early in the patient’s journey, inadequate and inappropriate pain relief for people with cognitive impairment may result in adverse events, hospital readmissions, increased functional decline, cognitive decline, behavioural changes and co-morbid mental illness. The aim of the study was to measure the impact of an observational pain assessment tool on analgesic administration time for cognitively impaired patients in the Emergency Department (ED).
Methods: An 18-month multi-site cluster controlled randomised trial was conducted in eight Sydney EDs. Sites (n=4) were randomised to receive the intervention. The intervention tested was the Pain Assessment in Advanced Dementia (PAINAD) tool. For the intervention sites patients, aged 65 years or older, suspected of a long bone fracture and with a confirmed cognitive impairment were screened for pain using the PAINAD. The primary outcome was time to first dose of analgesia.
Results: We enrolled 602 patients with 323 (54%) recruited from intervention and 279 (46%) non-intervention sites respectively. The medium time to analgesia was 82 minutes (IQR 45-151 minutes); intervention sites 83 (IQR 48-158 minutes) and non-intervention 82 minutes (IQR 41-147 minutes) respectively (p=.414). ED analgesia was provided to 180 (30%) patients within 60 minutes of being triaged. After adjusting for age, fracture type, arrival mode and triage category in a Cox regression model, there was no significant difference in time to analgesia between the two groups (HR 0.97, 95% CI 0.80-1.17, p 0.74).
Conclusion: While there was a small clinical trend that suggests PAINAD may improve analgesic administration time, improving practice is more complicated than the introduction of a tool. While PAINAD is a reliable and valid tool, socio-cultural, organisational and role factors may have a greater impact on ED pain management practice.
Professor Fry is Director of Research and Practice Development for Northern Sydney Local Health District and holds a Professorial Chair position with the University of Technology Sydney. Professor Fry has a strong emergency care background, has held CNC positions and is an authorised Nurse Practitioner (NSW). Professor Fry has extensive senior nursing experience and a proven research track with 118 peer reviewed publications and over $2.2million in grant, research tenders and or scholarship funding. Her program of research has led to significant state and national practice change. She was awarded Australasian emergency nurse of the year in 2005 and St George Hospital nurse of the year in 2001 and was a finalist in 2014 Nursing Excellence Awards for ‘Innovation in Research”. Professor Fry has also been awarded NSW Heath Care awards for innovative research making a difference for practice.
Dr Belinda Munroe1,2, Professor Kate Curtis1,2, Associate Professor Thomas Buckley2, Kate Ruperto1, Orinda Jones1, Tracey Couttie1, Dr Lou Atkins3
1Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, Australia, 2Sydney Nursing School, University of Sydney, Camperdown, Australia, 3Centre for Behaviour Change, University College, London, UK
Background: The emergency nursing assessment framework ‘HIRAID’ (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) improves patient assessment and communication skills of emergency nurses.¹ A range of facilitators and barriers were identified to potentially impact on the uptake and use of HIRAID.²
Aim: Design interventions to address facilitators and barriers, and optimise implementation of HIRAID in emergency nursing practice.
Methods: Implementation interventions were selected to target facilitators and barriers using the Behaviour Change Wheel.³ Resources were devised to enable delivery of interventions.
Results: A multimodal toolkit was devised to deliver behaviour change techniques selected, including feedback, demonstration, instruction, credible sources and prompts. The toolkit consists of educational and training resources for nurses and educators, an e-learning module, a preceptor program and simulation training exercises. A video was created to persuade nurses to use HIRAID in their practice, modelling executive support and demonstrating how to use the framework in practice. Electronic documentation templates, posters and reference cards were also designed to prompt use of HIRAID in the clinical environment.
Conclusion: This theory-informed toolkit has the potential to optimise implementation of HIRAID in emergency nursing practice. Further evaluation is needed to evaluate the impact of the HIRAID assessment framework and implementation strategy on clinical practice.
- Munroe B, Curtis K, Murphy M, Strachan L, Considine J, Hardy J, et al. A structured framework improves clinical patient assessment and nontechnical skills of early career emergency nurses: A pre-post study using full immersion simulation. J Clin Nurs. 2016;25(15-16):2262-74.
- Munroe B, Curtis K, Buckley T, Lewis M, Atkins L. Optimising implementation of a patient-assessment framework for emergency nurses: A mixed-method study. Journal of Clinical Nursing. Under review.
- Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science. 2011;6:42.
Belinda works a Clinical Nurse Consultant for the Emergency Departments across the Illawarra Shoalhaven. She completed her PhD in 2016, which included validating the first emergency nursing assessment tool internationally. Belinda also holds a peer nominated board position with the College of Emergency Nursing Australasia NSW, and is a Clinical Senior Lecturer at Sydney Nursing School.
Mr Matt Lutze1,2,3, Professor Margaret Fry2,5, Ms Glenda Mullen4, Dr Jane O’Connell2, Ms Danielle Coates4
1St George Hospital, Emergency Department, Kogarah, Australia, 2University of Technology Sydney, Faculty of Health, Ultimo, Australia, 3University of Sydney, Sydney Nursing School , Camperdown , Australia, 4Sydney Children’s Hospital Network, Emergency Department, Randwick, Australia, 5Director Research and Practice Development Nursing and Midwifery Directorate NSLHD , St Leonards, Australia
Objectives: This study sought to quantify and qualify the collaborative and secondary consulting clinical practice patterns of emergency nurse practitioners (ENPs). Within the literature there is extensive evidence of the direct clinical management provided by ENPs. However, ENP secondary activities incorporating consultation, advice and clinical support are not well described.
Design/Methods: This was a three-month prospective multicentre study design which explored ENP secondary consultations using an electronic medical record template. The template was designed to capture direct (patient contact) and indirect (staff advice / consultation) activities.
Results: ED presentations across the four sites were 54,970. ENPs were involved in the care of 2628 (5%) patients. Of the 2628 patients ENPs managed 2017 (77%) patients as the primary provider (primary consultations) and 611 (23%) as secondary consultations (direct and indirect contact).
Secondary consultations conducted by ENPs were on average 11.1 minutes (median 7.0 minutes). Of the secondary consultations 60% (n=367) required direct patient contact. Secondary consultations were commonly initiated by nurses (n=191; 31%) or emergency registrars (n=136; 22%). The majority (n=424; 69%) of secondary consultations involved patients with either musculoskeletal (n=238; 39%) and wounds and burns (n=186; 30%). ENPs requested 155 (21%) investigations and prescribing was performed on 144 (24%) occasions. Procedural support (n=303, 50%) was predominantly for wound management (n=141; 47%) or plaster/splints/crutches (n=113; 37%). When an ENP provided a secondary consultation, re-presentation rates were lower (1% compared to 6.5%).
Conclusion/Recommendations: The study highlights the invisible and valuable work of secondary consultations by ENPs. Approximately 25% of patients who received care from an ENP did so as a secondary consult. The study identified that all ED clinical staff utilised ENPs for expertise in patient management. The ENP secondary consultation template was quick and easy to use and could be adapted for other nurse practitioner specialties or other care providers.
Matt has been a nurse for almost 20 years and a nurse practitioner for more than 10. He has worked in the UK and Australia across ED, primary care, prehospital and critical care areas. Whilst Matt loves pretending he is a researcher, his attention to beer and its secondary benefits tend to enhance the quality of his discussions, usually about ultramarathon running or more important things like his kids and family… Oh the places you’ll go 🙂
Jo-anne Mcshane1, Dr Andrew Maclean1,2, Leanne Houston4, Helen Marquand4, Madeleine Smith1, A/Prof Mary O’Reilly2,3
1Emergency Department, Box Hill Hospital, Eastern Health, Box Hill, Australia, 2Eastern Health Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Box Hill, Australia, 3Department of Infectious Diseases, Eastern Health, Box Hill, Australia, 4Infection Prevention and Control, Eastern Health, Box Hill, Australia
The aim of the study was to see if triage and primary care Emergency Department (ED) nurses identified potentially infectious influenza patients in the Emergency Department and if correct isolation practices were being implemented.
The identification and management of patients with potentially infectious diseases is a challenging aspect of triage. The triage clinician has minutes to decide what may be potentially wrong with a patient and what immediate actions are needed. In addition, post triage often patients spend a significant amount of time in the waiting room of ED’s , potentially infecting other patients and staff.
A retrospective e-audit (using Symphony, the electronic Emergency Department Information System) with filters set to capture patients with influenza like illness (ILI) and an e-audit of influenza Polymerase Chain Reaction (PCR) ordered from Box Hill ED was undertaken from July- September 2016, during peak influenza season. Data collected: presenting complaint, observations, time to isolation and if Transmission Based Precautions (TBP) were implemented during their ED visit. Data was entered into Excel and analysed using IBM SPSS v22.
Detailed data analysis will be presented including follow-up action taken to address the gaps between current performance and best practice.
Triage and primary care nurses in the ED have an opportunity to improve their practise of identifying potential infectious patients by understanding the case definitions for ILI, applying surgical masks at triage, and isolating the patient until results of PCR testing are available. Identifying these patients early will help prevent transmission to other, sick vulnerable patients and staff both in ED and the inpatient setting.
The lead author is a recipient of an Medtronic Infection Control Scholarship
Jo-Anne is an enthusiastic Emergency Nurse with 20 yrs experience in Australian and overseas Emergency Departments. Jo-Anne is currently a research nurse at Box Hill Emergency Department and is particularly enthusiatic about Infection Prevention and Control practice and research.
Airway Team Dynamics
We want to show you how your performance as an Airway Team Nurse can improve patient care in critical situations.
Using skills and drills, team dynamics, simulations and other exercises we will explore the qualities needed to be an excellent airway nurse.
Ms Rebecca Collins1
1The Tweed Hospital, Nelson Bay, Australia
Imagine your personal ideal paradise location… Imagine you’re in your dream job but working on your own to provide medical treatment to a local population of 1200 with a transient population up to 4800. There is a GP available Monday to Friday and the on-call is shared equally but isolation coupled with limited support networks can be a gruelling and a fatiguing environment to work in.
What options do you have to support your practice when working in private enterprise in an isolated location?
I was employed to coordinate the opening of the only Medical Centre in a remote location with difficult, if not impossible access in poor weather. I was responsible for the Primary Health Care needs and emergency presentations of the population. Whilst I had a GP in the practice he was not permanently located on site.
A support relationship was developed using the telehealth model TEMSU (Telehealth Emergency Management Support Unit). Telehealth is now used extensively but for Queensland Health this was a primary initiative to bridge the gap between a private remote location and the public hospitals involved in an attempt to reduce the amount of retrievals required. The service allowed for contact with specialist services for close to 24 hours a day and review of unwell patients. It aided in the decision making process of transfer mode for retrieval patients either via water (with or without escort) or heliport. The results were not what was expected in regards to a reduction in retrievals for TEMSU.
Additional benefits of the system included support and education for medical personnel and improved health care services for patients. The accidental pilot generated discussion and research into improvement of existing services to meet gaps that may not have previously been met.
I am an Emergency Nurse my full title is Nurse Practitioner Primary Healthcare/Emergency. I have been working as a Registered Nurse since the mid 90’s. More recently in a Nurse Practitioner role since 2007. My education and employment has been through rural, metropolitan and tertiary hospitals throughout NSW and QLD in paediatrics, midwifery and emergency. I have dabbled in private health care along the way. I am an adventurous person and have dragged my family to remote locations while they have evolved in these environments my career has also developed and I have learnt and experienced things I would never have done in only one area of nursing.
Tonya Donnelly1, Dr Amy Johnston2, Nerolie Bost1, Dr Michael Aitken1, Cary Strong3, Jo Timms1, Kate Gilmore1, Professor Julia Crilly2
1Dept Emergency Medicine, Gold Coast Health , Southport, Australia, 2Dept Emergency Medicine Gold Coast Health And Menzies Health Institute Qld , Southport, Australia, 3Gold Coast LASN, Queensland Ambulance Service, Ormeau, Australia
You’re off to great places, but why do you go? So you’ve set up a tent – but what does it show?
Background: Emergency department (ED) crowding and ambulance transportation rates are known to be increasing annually. The implementation of ED avoidance strategies during events such as mass-gatherings can be an important. One such strategy, the ‘Schoolies week’ health tent has been in operation for 10+ years. Evidence in support of its use for ED avoidance has been primarily anecdotal.
Methods: This was a retrospective observational study. The study sample included all 16-18 years old patient presentations made to the ED over a three week period (pre, during, post Qld Schoolies week) and to a temporary medical tent (during Qld Schoolies week) in 2014. Patient information from the ED and ambulance service databases were linked. Descriptive and inferential statistics were used for analysis.
Results: A total of 1,028 patient presentations were made by the 16-18 year age group to the ED and/or health tent over the three week study period ( (120 pre, 684 during, 224 post Qld Schoolies week). During the schoolies week, a total of 420 presentations were made to the health tent with an average of 60 per night. The majority (n=394) were seen and discharged from the tent while some (n=26) required further ED care.
Conclusions: The results suggest that a temporary facility for one week during the Schoolies mass-gathering event was a useful ED avoidance strategy for young adult school leavers. Pressure on the hospital EDs and ambulance services was relieved, and access by local residents maintained, because the on-site tent diverted young people away from the local EDs. Given the increase in ED crowding and pressures on ambulance services, such care models may be worth considering for mass gathering events in other locations.
Tonya Donnelly is a highly experienced award-winning ED CNC, who has held the disaster/mass gathering portfolio at Gold Coast Health Service for ~10 years. She is committed to developing and implementing evidence-based ED avoidance strategies that really reduce patient load and enhance care delivery in local EDs. She is passionate about the establishment of hospital avoidance programs particularly around mass gatherings.
Amy Johnston is a conjoint research fellow in Emergency Care, based between Gold Coast Health and Menzies Health Institute Queensland/School of Nursing and Midwifery Griffith University, seconded from a senior lecturer position at Griffith University. She is deeply committed to bringing research skills and outcomes to emergency staff. She is a widely published and cited academic and registered nurse with experience in a range of research techniques. Her love of clinical research is heartfelt and (hopefully) infectious. She is involved in HDR student supervision and onsite development of ED staff research skills.